Pancreatitis from posterior gastric wall perforation by ingested metallic wire—case report and review of literature

Gastric and duodenal perforation from ingested organic and inorganic foreign bodies, such as sewing needles, toothpick, metallic wires, fish and chicken bone, are uncommon incidents as most foreign bodies pass in the faeces. The perforated foreign body can at times migrate and either penetrate causing traumatic injury or incite inflammation with formation of abscesses or pseudo-tumours in the adjacent organs such as the liver and pancreas. We report one such case of pancreatitis in a child resulting from a metallic wire perforating the posterior gastric wall and penetrating the pancreas. The findings were detected on CT and the foreign body was extracted endoscopically. We also present review of literature on similar case reports.

A repeat ultrasonography was performed on Day 4 and revealed mildly bulky pancreas, fluid in the lesser sac and in the pelvis.The complete blood picture and liver function tests were normal.The serum amylase (596 IU l −1 ) and serum lipase (396 IU l −1 ) values were found to be elevated.
Contrast-enhanced CT scan of the abdomen revealed a bulky and oedematous pancreas with a 4 × 3.5 cm area of parenchymal necrosis in the distal body (Figure 1).There was fat stranding and free fluid in the lesser sac and in the left anterior pararenal space, caudally extending along the left lateral conal and Gerota's fascia with free fluid in the pelvis (Figure 1).A thin curvilinear high density foreign body of 3.5 cm length was noted in the antral region of stomach (Figure 1), extending across the posterior wall and piercing into the pancreatic parenchyma in the region of head, cranial to the level of the pancreatic duct.There was no pneumoperitoneum.A diagnosis of acute necrotising pancreatitis caused by transgastric migration of a penetrating foreign body was made.The child denied conscious intake of any foreign body and so did the family.

tReatMent anD outCoMe
A fluoroscopic examination was performed by the Department of Medical Gastroenterology, which showed a thin curvilinear high density foreign body in the upper abdomen corresponding to the level of gastric antrum (Figure 2a).Endoscopy showed a sharp curvilinear metallic wire piercing the posterior wall of antrum of the stomach (Figure 2b).This was removed intact as a single piece with rat tooth biopsy forceps (Figure 2c).He was then conservatively managed for pancreatitis, improved symptomatically, and was discharged in stable condition after 5 days.
Informed consent for the case to be published (including case history, data and images) was obtained from the child's father.

DisCussion
Of the various causes of pancreatitis, trauma by blunt or penetrating injury is an uncommon cause.Even more unusual and infrequent is direct traumatic injury from an ingested foreign body perforating the upper GI tract. 1,2 3hile a majority of the ingested foreign bodies pass in the faeces, only about 1% are known to cause perforation. 1 2 Apart from the cricopharyngeal junction and the oesophageal sphincter, points of angulation or narrowing in the upper gastrointestinal (GI) tract such as the pylorus, duodenal curve and the ligament of Treitz are the common sites of perforation. 4The perforation may either be acute or chronic, at times with the foreign body getting embedded and taking months to erode through the gastric or duodenal wall, hence the timeline of presentations of symptoms can widely vary. 57][8] One of the earliest literature of ingested foreign bodies perforating the upper GI tract and migrating into the pancreas was by Hashmonai et al, who reported a series of 10 cases of upper GI perforation by sewing needle, out of which four had perforated the duodenum and migrated into the pancreas. 9 review of literature, we found 20 case reports of pancreatic involvement by ingested sharp objects such as fishbone, sewing needle and toothpick penetrating the stomach or duodenum, out of which six patients had developed features of pancreatitis.
Table 1 summarizes these case reports.However, we found only three case reports of ingested metallic wires perforating the upper GI tract and penetrating the pancreas, out of which one patient had developed signs of pancreatitis.Wu et al. in 2006 reported a similar case of a 45/M with pain abdomen and with rising amylase and lipase levels, in whom a piece of wire had perforated the stomach and migrated into the head of the pancreas, resulting in a peripancreatic abscess.The wire was detected on CT and removed on laparoscopy and there was no known history of its ingestion by the patient. 4Hao et al. in 2022 reported the case of 36/F presenting with dull epigastric pain, whose CT demonstrated a similar liner high density foreign body extending from the posterior gastric wall and embedded in the pancreas; a 3 cm metallic wire was removed on surgery and was assumed to have been ingested from remnants of a metallic brush used to clean pots and pans. 25There was, however, no abscess formation/ inflammation or pancreatitis in this patient.Sulieman et al. in 2022 reported a case of an accidentally ingested metallic grill brush wire masquerading as peripancreatic and paraduodenal inflammation on CT.Since the serum amylase and lipase values were normal, an MRI of the upper abdomen was performed for further evaluation, which revealed a metallic object presenting as susceptibility artefact within the paraduodenal inflammation; on push enteroscopy, a metallic brush wire/bristle was found perforating the third part of duodenum and extracted. 7 accidentally or unknowingly ingested foreign body perforating the GI tract may at times be asymptomatic or present with vague symptoms several years later, but the potential morbidity resulting from a migrating foreign body penetrating the pancreas can be significant. 2,3,5aging with CT of the abdomen plays a major role in diagnosis.The presence of a small linear high-density object located intramurally, outside the bowel or embedded in the viscera in any patient with upper abdominal pain should raise the suspicion of perforated foreign body from upper GI tract, even in the absence of a history of foreign body ingestion at the time of presentation.The presence of such an object within a collection or phlegmonous mass is even more characteristic.Imaging can not only aid in the diagnosis but also in the decision-making between endoscopic extraction vs laparoscopy or laparotomy for extraction. 1 The proximal end of the curvilinear foreign body was seen withing the gastric lumen on CT in our case, thus helping expedite the process of endoscopic retrieval.Indirect signs such as presence of surrounding fluid collection, air pockets, peritoneal inflammation in the vicinity or bowel wall oedema can point to the site of perforation even when the foreign body has migrated. 5ough the imaging findings were characteristic of a foreign body on CT in our case and its presence and nature were demonstrated on endoscopy and upon its extraction, there was no history of its ingestion.
Poorly conspicuous small calibre foreign bodies may pose a great diagnostic challenge, as the surrounding inflammation may obscure its visibility on CT.In such cases, further evaluation with

Figure 1 .
Figure 1.Axial CECT at the level of body of pancreas (a), at the level of head and body caudal to section 1a (b) and coronalcurved MPR images (c).The pancreas is bulky and oedematous with fat stranding and fluid in the lesser sac, left pararenal and lateral conal spaces (small yellow arrows).A focal area of necrosis in the form of parenchymal non-enhancement (black Asterix in b) is seen in the body of pancreas.The dashed yellow arrow in Figure 1a, b and c points to a curvilinear high density foreign body, whose proximal end is in the antropyloric canal of stomach (a) and distal end in embedded in the head of pancreas (b).CECT, contrast-enhanced CT; MPR, multiplanar reconstruction.

Figure 2 .
Figure 2. (a) Fluoroscopy of the upper abdomen in left lateral position (with endoscope in the stomach) demonstrates a thin curvilinear high-density object at the level of antropyloric canal (dashed black arrow).(b) Endoscopy demonstrated a thin metal wire in the gastric antrum perforating the posterior wall.(c) A 3.5 cm curvilinear metal wire was extracted with a rat tooth forceps.

Table 1 .
List of case reports in chronological order on ingested fishbones, sewing needles and toothpicks that perforated the upper GI tract and involved the pancreas The patients are likely to ingest tiny metallic wires/needles unknowingly.(b) Patients can be asymptomatic despite a perforation.(c) Chronic perforations can present late, at times after months to years from the time of ingestion.